Postoperative Anticoagulation in Patients with Mechanical Heart Valves Following Surgical Treatment of Subdural Hematomas

Abstract

Background Thromboembolic events and anticoagulation-associated bleeding events represent frequent complications following cardiac mechanical valve replacement. Management guidelines regarding the timing for resuming anticoagulation therapy following a surgically treated subdural hematoma (SDH) in patients with mechanical valves remains to be determined. Objective To determine optimal anticoagulation management in patients with mechanical heart valves following treatment of SDH. Methods Outcomes were retrospectively reviewed for 12 patients on anticoagulation therapy for thromboembolic prophylaxis for mechanical cardiac valves who underwent surgical intervention for a SDH at the Johns Hopkins Hospital between 1995 and 2010. Results The mean age at admission was 71 years. All patients had St. Jude’s mechanical heart valves and were receiving anticoagulation therapy. All patients had their anticoagulation reversed with vitamin K and fresh frozen plasma and underwent surgical evacuation. Anticoagulation was withheld for a mean of 14 days upon admission and a mean of 9 days postoperatively. The average length of stay was 19 days. No deaths or thromboembolic events occurred during the hospitalization. Average follow-up time was 50 months, during which two patients had a recurrent SDH. No other associated morbidities occurred during follow-up. Conclusion Interruptions in anticoagulation therapy for up to 3 weeks pose minimal thromboembolic risk in patients with mechanical heart valves. Close follow-up after discharge is highly recommended, as recurrent hemorrhages can occur several weeks after the resumption of anticoagulation.

Anti-Coagulation and Deep Brain Stimulation: Never the Twain Shall Meet?

“…In a retrospective review of 12 patients on warfarin for mechanical heart valves and requiring evacuation of chronic subdural haematoma, their anti-coagulation was reversed and withheld for a mean of 14 days from admission and 9 days post-operatively. No thromboembolic events occurred [2]. A further study of 26 patients with mechanical valves who had suffered from intra-cranial haemorrhage showed that VTE was unlikely to occur when anti-coagulation was withheld for up to 7 days.…”

“…However, the anti-coagulated patient who requires neurosurgery can pose the most serious dilemmas. Patients who have mechanical cardiac valves or recurrent pulmonary embolism (PE), for example, often require lifelong anti-coagulation, the reversal of which can increase the risk of venous thromboembolism (VTE) or stroke [2]. This has to be balanced against the theoretical increased risk of intra-cranial haemorrhage, which makes anti-coagulant therapy a relative contraindication for neurosurgery.…”

Management of Life-Threatening Bleeding in Patients With Mechanical Heart Valves

“…In an observational study involving 137 patients with mechanical heart valves who presented with intracranial hemorrhage, Kuramatsu et al observed that holding off anticoagulation for two weeks is safe and its earlier resumption should only be considered in high-risk patients [27]. Similarly, Amin et al retrospectively observed 12 patients with mechanical heart valves who had surgical treatments for subdural hematoma and were followed up for a mean duration of 50 months [26]. In this study, anticoagulation was held off for an average of two weeks.…”

Subdural Hematoma and Oral Anticoagulation: A Therapeutic Dilemma from the Neurosurgical Point of View

“…According to the European Society of Cardiologists and the European Stroke Initiative, it has been recommended to withhold all oral anticoagulation therapy for 7 to 14 days after oral anticoagulation-related intracranial hemorrhage, even in high-risk cases with mechanic heart valves. [30][31][32][33] Notably, also in our study population there was no early thromboembolic complication after stopping the oral Fig. 1 Survival curves of the two study groups (blue: without oral anticoagulation; green: with oral anticoagulation).…”